Four Dimensional Symptom Questionnaire (4DSQ)

Author: Berend Terluin, MD, PhD

Important announcement
As per April 2014 the cut-off points of the 4DSQ anxiety scale have been revised in agreement with new data published in BMC Psychiatry. The new cut-off points are ≥4 and ≥10.


The 4DSQ is a self-rating questionnaire measuring four dimensions of common psychopathology: distress, depression, anxiety and somatization. The 4DSQ was developed in general practice. The principal aim of the 4DSQ is to distinguish between stress-related syndromes (denoted as ‘stress’, ‘burnout’, ‘nervous breakdown’ or in Dutch ‘overspanning’ or ‘surmenage’) and psychiatric disorders (i.e. depression and anxiety disorders).


The Distress scale measures nonspecific symptoms of psychopathology, ranging from worrying and irritability to fatigue and demoralization. As a general nonspecific component distress is always part of the symptomatology of anxiety and depressive disorders, in which case distress accompanies specific symptoms of anxiety or depression. Distress alone, or in combination with somatization, is characteristic of uncomplicated stress-related syndromes that are commonly encountered in general practice. The Distress score is associated with any psychosocial diagnosis as established by general practitioners (GPs) in general practice patients.The 4DSQ is a self-rating questionnaire measuring four dimensions of common psychopathology: distress, depression, anxiety and somatization. The 4DSQ was developed in general practice. The principal aim of the 4DSQ is to distinguish between stress-related syndromes (denoted as ‘stress’, ‘burnout’, ‘nervous breakdown’ or in Dutch ‘overspanning’ or ‘surmenage’) and psychiatric disorders (i.e. depression and anxiety disorders).

The Depression scale measures severe anhedonia and depressive thoughts, including suicidal ideation, symptoms that are characteristic of depressive disorders. The Depression score indicates the probability of having a major depressive disorder.

The Anxiety scale measures free floating anxiety, panic, and phobic anxiety, symptoms that are specific to the anxiety disorders. The Anxiety score indicates the probability of having one or more anxiety disorders.

The Somatization scale measures a range of common physical symptoms, known to be related to distress or psychopathology. Examples are headache, palpitations, nausea, and muscle aches. Moderate levels of somatization commonly accompany psychological distress that is not necessarily pathologic. High levels of somatization reflect pathological psychological mechanisms such as 'senstisation', illness attributes and health anxiety. The Somatization score is associated with the GP’s suspicion of a psychosocial background in patients presenting with physical symptoms.

Psychometric properties

Reliability of the 4DSQ scales is high with alpha-coefficients ranging from 0.84 to 0.94 and test-retest coefficients ranging from 0.89 to 0.94. The correlations between the 4DSQ-scales range from 0.35 to 0.71. The four-factor structure of the 4DSQ has been confirmed.


The 4DSQ can be used both in clinical practice, especially in general practice and occupational medicine, as well as in research.


DistributionThe 4DSQ is freely available for non-commercial use, for instance in clinical practice and research. People who wish to make commercial use of the 4DSQ are invited to contact the author []. We would appreciate it when potential 4DSQ-users state their name, profession, address and intended use of the 4DSQ.



  1. Terluin B, Van Marwijk HWJ, Adèr HJ, De Vet HCW, Penninx BWJH, Hermens MLM, Van Boeijen CA, Van Balkom AJLM, Van der Klink JJL, Stalman WAB: The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 2006, 6:34.
  2. Terluin B, Van Rhenen W, Schaufeli WB, De Haan M: The Four-Dimensional Symptom Questionnaire (4DSQ): measuring distress and other mental health problems in a working population. Work Stress 2004, 18:187-207.
  3. Terluin B, Duijsens IJ: 4DKL-handleiding. Handleiding van de Vierdimensionale Klachtenlijst [4DSQ manual. Manual of the Four-Dimensional Symptom Questionnaire]. Leiderdorp: Datec; 2002.
  4. Terluin B: De Vierdimensionale Klachtenlijst (4DKL). Een vragenlijst voor het meten van distress, depressie, angst en somatisatie [The Four-Dimensional Symptom Questionnaire (4DSQ). A questionnaire to measure distress, depression, anxiety, and somatization]. Huisarts Wet 1996, 39:538-547.
  5. Terluin B: De Vierdimensionale Klachtenlijst (4DKL) in de huisartspraktijk. [The Four-Dimensional Symptom Questionnaire (4DSQ) in general practice]. De Psycholoog 1998, 33:18-24.
  6. Terluin B: Wat meet de Vierdimensionale Klachtenlijst (4DKL) in vergelijking met enkele bekende klachtenlijsten? [The Four-Dimensional Symptom Questionnaire (4DSQ) compared with some well-known symptom questionnaires]. Tijdschrift voor Gezondheidswetenschappen 1998, 76:435-441.
  7. Terluin B: Naar een nieuwe indeling van psychosociale problemen in de eerste lijn. Een secundaire analyse van de symptomatologie van 396 huisartspatiënten en 67 cliënten van het algemeen maatschappelijk werk [To a new classification of common mental disorders in primary care. A secondary analysis of the symptoms of 396 general practice patients and 67 social work clients]. Huisarts Wet 1998, 41:219-228,245.
  8. Reliability, precision and smallest detectable change. Additional file to reference 1
  9. Responsiveness. Additional file to reference 1
  10. Respondent burden. Additional file to reference 1
  11. Terluin B, Rijmen F, van Marwijk HWJ, Stalman WAB. Waarde van de Vierdimensionale Klachtenlijst (4DKL) voor het detecteren van depressieve stoornissen [The Four-Dimensional Symptom Questionnaire's (4DSQ) value for the detection of depressive disorders]. Huisarts Wet 2007; 50: 300-5.
  12. van Rhenen W, van Dijk FJH, Schaufeli WB, Blonk RWB. Distress or no distress, that's the question: A cutoff point for distress in a working population. J Occup Med Toxicol 2008; 3:3.

  13. Terluin B, Terluin M, Prince K, Van Marwijk HWJ. De Vierdimensionale Klachtenlijst (4DKL) spoort psychische problemen op. [Nascholing] Huisarts Wet 2008; 51: 251-5. 
  14. Terluin B, Terluin M, Prince K, Van Marwijk HWJ. The Four-Dimensional Symptom Questionnaire (4DSQ) detects psychological problems. [CME]  English translation of reference 13.

  15. Terluin B, Neeleman-van der Steen CWM, Verbraak MJPM, Smitskamp JF, Duijsens IJ. Kunnen SCL-90-scores worden voorspeld op basis van 4DKL-scores? Vergelijking van de Vierdimensionale Klachtenlijst (4DKL) en de Symptom Checklist (SCL-90). De Psycholoog 2009; 44: 498-507.

  16. Braam C, van Oostrom SH, Terluin B, Vasse R, de Vet HCW, Anema JR. Validation Study of a Distress Screener. J Occup Rehabil 2009; 19(3):231-7.

  17. Brouwers EPM, Terluin B, Tiemens BG, Verhaak PFM. Predicting return to work in employees sick-listed due to minor mental disorders. J Occup Rehabil 2009; 19: 323-32.
  18. Terluin B, Brouwers EPM, van Marwijk HWJ, Verhaak PFM, van der Horst HE. Detecting depressive and anxiety disorders in distressed patients in primary care; comparative diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) and the Hospital Anxiety and Depression Scale (HADS). BMC Fam Pract 2009; 10:58.
  19. Terluin B, van Rhenen W, Anema JR, Taris TW. Psychological symptoms and subsequent sickness absence. Int Arch Occup Environ Health 2011; 84(7):825-37
  20. Langerak W, Langeland W, van Balkom AJLM, Draisma S, Terluin B, Draijer N. A validation study of the Four-Dimensional Symptom Questionnaire (4DSQ) in insurance medicine. Work 2012; 43(3): 369-80
  21. Czachowski S, Terluin B, Izdebski A, Izdebski P. Evaluating the cross-cultural validity of the Polish version of the Four-Dimensional Symptom Questionnaire (4DSQ) using differential item functioning (DIF) analysis. Family Practice 2012; 29: 609-15
  22. Tebbe BBM, Terluin B, Koelewijn JM. Assessing psychological health in midwifery practice: A validation study of the Four-Dimensional Symptom Questionnaire (4DSQ), a Dutch primary care instrument. Midwifery 2013; 29: 608–15
  23. Terluin B, Oosterbaan DB, Brouwers EP, van Straten A, van de Ven PM, Langerak W, van Marwijk HW. To what extent does the anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) detect specific types of anxiety disorder in primary care? A psychometric study. BMC Psychiatry 2014; 14(1):121.
  24. Terluin B, Smits N, Miedema B. The English version of the four-dimensional symptom questionnaire (4DSQ) measures the same as the original Dutch questionnaire: A validation study. Eur J Gen Pract 2014.
  25. Roelen CAM, Hoedeman R, van Rhenen W, Groothoff JW, van der Klink JJL, Bültmann U. Mental health symptoms as prognostic risk markers of all-cause and psychiatric sickness absence in office workers. Eur J Public Health 2014; 24(1): 101-5.
  26. Terluin B, Verbraak M. Validiteit van de Vierdimensionale Klachtenlijst (4DKL) in de ambulante geestelijke gezondheidszorg. Tijdschrift voor Klinische Psychologie 2014; 44(3): 198-211.
  27. Terluin B, Ashraf F. Differential item functioning (DIF) and differential test functioning (DTF) analysis of the Urdu Four-Dimensional Questionnaire (4DSQ). Unpublished short report. January 2015.
  28. van Hoffen MFA, Joling CI, Heymans MW, Twisk JWR, Roelen CAM. Mental health symptoms identify workers at risk of long-term sickness absence due to mental disorders: prospective cohort study with 2-year follow-up. BMC Public Health 2015; 15(1):1235.
  29. van der Leeuw G, Gerrits MJ, Terluin B, Numans ME, van der Feltz-Cornelis CM, van der Horst HE, Penninx BWJH, van Marwijk HWJ. The association between somatization and disability in primary care patients. J Psychosom Res 2015; 79(2):117-22.
  30. Dijkstra-Kersten SMA, Sitnikova K, van Marwijk HWJ, Gerrits MMJG, van der Wouden JC, Penninx BWJA, van der Horst HE, Leone SS. Somatisation as a risk factor for incident depression and anxiety. J Psychosom Res 2015; 79(6):614-9.
  31. Geraghty AWA, Stuart B, Terluin B, Kendrick T, Little P, Moore M. Distinguishing between emotional distress and psychiatric disorder in primary care attenders: A cross sectional study of the four-dimensional symptom questionnaire (4DSQ). J Affect Disord 2015; 184:198-204.
  32. Chambe J, Le Reste JY, Maisonneuve H, Sanselme AE, Oho-Mpondo J, Nabbe P, Terluin B. Evaluating the validity of the French version of the Four-Dimensional Symptom Questionnaire with differential item functioning analysis. Fam Pract 2015;  32: 474-9.
  33. Terluin B, Unalan PC, Turfaner SipahioÄŸlu N, Arslan Özkul S, van Marwijk HWJ. Cross-cultural validation of the Turkish Four-Dimensional Symptom Questionnaire (4DSQ) using differential item and test functioning (DIF and DTF) analysis. BMC Fam Pract 2016; 17(1):53.
  34. van Hoffen MFA, Twisk JWR, Heymans MW, de Bruin J, Joling CI, Roelen CAM. Psychological distress screener for risk of future mental sickness absence in non-sicklisted employees. Eur J Public Health 2016; 26(3):510-2.
  35. Ailliet L, Rubinstein SM, Knol D, van Tulder MW, de Vet HCW. Somatization is associated with worse outcome in a chiropractic patient population with neck pain and low back pain. Man Ther 2016; 21:170-6.
  36. den Boeft M, Twisk JWR, Hoekstra T, Terluin B, Penninx BWJH, van der Wouden JC, Numans ME, van der Horst HE. Medically unexplained physical symptoms and work functioning over 2 years: their association and the influence of depressive and anxiety disorders and job characteristics. BMC Fam Pract 2016; 17:46.
  37. Tebbe BBM, Terluin B, van Poppel MNM. Measuring maternal mental health using the Dutch Four-Dimensional Symptom Questionnaire (4DSQ): Pregnancy-related item bias across the perinatal period. Midwifery 2016; 40:192-9.
  38. Terluin B, Smits N, Brouwers EPM, de Vet HCW The Four-Dimensional Symptom Questionnaire (4DSQ) in the general population: scale structure, reliability, measurement invariance and normative data: a cross-sectional survey. Health Qual Life Outcomes 2016; 14(1):130.
  39. Terluin B. Psychometric validation of the Swedish Four-Dimensional Symptom Questionnaire (4DSQ) using differential item and test functioning (DIF and DTF) analysis. Unpublished short report. September 2017.
  40. Magnée T, de Beurs DP, Terluin B, Verhaak PF. Applying computerized adaptive testing to the Four-Dimensional Symptom Questionnaire (4DSQ): A simulation study. JMIR Ment Health 2017; 4(1): e7.
  41. Sitnikova K, Dijkstra-Kersten SMA, Mokkink LB, Terluin B, van Marwijk HWJ, Leone SS, van der Horst HE, van der Wouden JC. Systematic review of measurement properties of questionnaires measuring somatization in primary care patients. J Psychosom Res 2017; online first.
  42. Van Bebber J, Wigman JTW, Wunderink L, Tendeiro JN, Wichers M, Broeksteeg J, Schrieken B, Sytema S, Terluin B, Meijer RR. Identifying levels of general distress in first line mental health services: can GP- and eHealth clients' scores be meaningfully compared? BMC Psychiatry 2017; 17(1):382.

Download 4DSQ [In English or in Dutch (4DKL) or other language versions (French, German, and more)